Radiation Therapies
L39553
This policy covers use of advanced external-beam radiation modalities (IMRT, VMAT, SRS, SBRT) when highly conformal planning, image guidance, and documented medical necessity are required to spare critical normal tissues or to achieve curative/oligometastatic intent in medically appropriate patients. Coverage requires specific documentation (diagnosis, target volumes, doses, planning type, DVHs, QA) and performance status criteria for stereotactic therapies; IMRT/SBRT/SRS are not covered when conventional techniques suffice, in certain urgent palliative settings, or when patient/technical factors prevent safe, reproducible delivery. SBRT is limited to 1–5 fractions and SRS generally to lesions <5 cm with additional performance and life-expectancy requirements for brain metastases.
"IMRT is indicated when highly conformal dose planning is required to spare adjacent normal tissues as a specific clinical benefit for the individual patient."